Loading...
Skellie Jr., Edward NEW YORK STATE DEPARTMENT OF HEALTH - "' nil Vital Records Section Burial rial - Transit Permit Name First Middle Last Sex Edward Albert . Skellie Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, September 25, 2017 56 War or Dates IPlace of Death Hospital, Institution or City, Town or Village Moreau Street Address Route 9 Manner of Death❑Natural Cause X❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending u Circumstances Investigation 21 Medical Certifier Name Title Michael Sikirica , Dr. Address 50 Broad Street Ste 1 Waterford, NY 12188 Death Certificate Filed District Number Regis r Number City, Town or Village Moreau �5((ti / .-❑Burial Date Cemetery or Crematory September 27, 2017 Pine View Crematoryii❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed -1--] Removal and/or Held and/or Address Hold at Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number = Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ILI E� Permission is hereby ranted to dispose of the human describ ab'e as indicated. Date Issued Q i Registrar of Vital Statistics eatte{ / (sign ture) District Number 95�a- Place �J ( 6L(fio/c/s e �fC� 1/1 / r. = I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: -' Date of Disposition 09/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) r (grave number) Name of Sexton or Person in Charge of Pre ises Clr 364414 (pie se print) Signature ` a iEmli"� Title (over) DOH-1555 (02/2004)